GW1-2022-03630_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A ft rt.
ft. it
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased;we119 OR LINER if a cable
NW Poole Well and Pump Company FROM TO D TER THICKNESS li DIATERIA
Company Name ft. ft. in. - 1 /� � � I t
lb.INNER CASING OR TUBING eothermal closedE
2.Well Construction Permit#: w ,.,5(/ PROM TO DIAMETER THICKNESS MATERIALList all applicable well construction permits ri.e.UIC,CountyPVe,Variance,etc.) R. ft.
3.Well Use(check well use): ft ft, in.
Water Supply Well: `17.SCREEN.
FROM - TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial esidential Water Supply(shared) 18.GROUT
011TI ation ❑Wells>100,000 GPD FROM TO MATE EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if alicableFROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fr.
i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color hard soilfrock a rain size etc.
tt. ft. I C
4.Date Well(s)Completeda-q Well ID# tt. ft.
5 Well Location:
fttn
N
t
ere ft ft.m- h0i!1'te5
Facility/Owner Name FacilityID#(if applicable) ft ft..
��= LI tf tic ft ft.
amp c
Physical Address,(Ciity,and Zip 22904 ft. ft.
iV 1��!ry 21.REMARKS
County UIVK
Parcel Identification No.(PIN) Infofiari t1 fOC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,,one]at/long is sufficient)N ^7g- -1
I J I S W 22.Certifica'
2-9
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCertified Well Contractor Date
Dysigning this form,/hereby certify that the ivell(s)teas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has beenprovided to the well;owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft.)
For multiple wells list all depths iftli ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Zo (R) 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
If water lerel is above casing,use'+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
H.Borehole diameter: (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-L Ibp Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: Copy WR CCPCUA
S 24d.For Water Wells nroducine over 100,000 GPD:Co to D
13a.Yield(gpm) `�' Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb. h
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018